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j APPLICATION FOR PERMIT /97 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT f . <br /> 1601 E. HAZEL T ON AVE';STOCKTON, CA Vim' <br /> Telephone (209) 466-6781 A/0 <br /> " PERMIT EXPIRES 1 YEAR FROM DATE-ISS, ED <br /> (Complete in Triplicate) ' a <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welt/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. } <br /> Job Address n t <br /> � Y' City A Lot Size o M <br /> 33 9 <br /> Owner's Name �J� ►.� ?�AllQr`"Address ✓ Phone �' <br /> r J Contract-' l Address <br /> a` <br /> ✓r No_3 3.,�Phone 7339\!' <br /> TYPE OF'WELLYPU P: NEW WELL T WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATIO ❑ ,SYSTEM REPAIR El OTHER Q <br /> K S <br /> tip ..ri <br /> DISTANCE TO NEAREST: SEPTIC TANK LA � Jag A-0NES t' / DISPOSAL FLD,_ PROP. LINE Z�� <br /> FOUNDATION 014 'AGRICULTURE WELL _i OTHER WELL !!!�-"_- PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -a� r <br /> ❑ IndustrialKbpen Bottom ❑ Manteca Dia. of Well Excavation 13 i1. Dia. of Well Casing <br /> omestic/Pfi"nate ❑_Gra,vel Pack ... 0 Ty_O_e�-pf_,.Casing t-- <br /> O Pubfic ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irriation, t �' <br /> gApprox. Depth ❑ Eastern Surface Seal Installed by - <br /> Repair,Work Done [I Type of Pump H.P. State Work pone <br /> kj <br /> Well Destruction ❑ 'Well Diameter Sealing Material (top 501 r <br /> Depth Filler Material (Below 50') cj <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> I available within 200 feet.) <br /> i <br /> Installation will serve: Residence_ Commercial� Other _- <br /> Number of living units: Number of bedrooms t <br /> Character of soil to a depth of 3 feet: Water table depth r <br /> SEPTIC TANK s ❑ 'Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑. $ 1� Method of Disposal <br /> k .ti o- <br /> k Distance to nearest: Well Foundation Property Lrne� <br /> LEACHING LINE C7 No. & Length of lines Total length/size <br /> FILTER BED j ❑ Distance to nearest: Well Foundation 14 <br /> Property Line / <br /> f <br /> SEEPAGE PITS- ❑ Depth Size Number ;4 <br /> ^r <br /> SUMPS s ❑ Distance to nearest: Well 1_0 Foundation Property Line A/ <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws,'ana T <br /> rules and regulations of the San Joaquin Local Health District. <br /> HOm&Iowne}-or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subjemto workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the following:"I certify that in'the,performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant m st II for all__requir inspecti pleta drawing on reverse side. <br /> 1 <br /> Signed '' -Title: ' 4 Date: <br /> s ' <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted:by �� " r4 s DateO Area T <br /> Pit or Grout Inspection by j� ate 7r 1>4/ Final Inspection by ` Date <br /> Additional Comments: " J <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621�-i" ❑ Manteca 823-7104 0 Tracy 835-6385 ! / <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO 0 OMOM UNT DUEe_ — TUN REMITTED 'CASH"'! RECEIVED.BY DATE PERMIT'NO. <br /> + EH 13-24(REV.I B5) <br /> EH 14-26 <br /> i <br />